Referrals from general health care providers to specialists must often be made in the modern health care system. Such referrals have been done by telephone or by prescription slips, sending patients from one provider to another with long waits for appointments even when critical care was needed. Referrals were often incorrect and done for incorrect reasons, without proper documentation and/or follow-up to see that proper care was available to or was obtained by particular patients.
As healthcare providers assemble multi-enterprise based health systems to serve people in their communities, particularly for example the poor, the uninsured, and the underinsured, the size and scope of operations places unique new demands on their people, their processes and, unfortunately, their patients. The use of hand written referrals, sent by fax, couriers, and mail are required to bridge across the various information systems and operating policies and procedures inherent in any cross enterprise operation. As providers examine methods to improve these operations, they continue to focus on these three key essentials:                Access to care        Continuity of care        Quality of careThe present methods of handling referrals in such a healthcare system allow a number of problems to amass.        
Many of specialty clinics have significant overloads of patients. At the same time, significant numbers of the patients in the appointment books are in the wrong place, or have a low clinical need (or “acuity”), while many other patients who truly need the skills of the resource are unable to get timely appointments.
Patients arrive without complete workup information available to the specialist. Today's system, too often, relies more on “who you know” rather than on the pure clinical facts of the case. Many times, patients must wait far too long to get appropriate medical treatment.
The lack of consistent feedback to referring physicians and of convenient routing processes breaks down the continuity of care. In too many cases, specialists become primary care physicians for the patients.
Problems amplify as one moves geographically and structurally away from a health care community's traditional main campus. Community clinics, both intra-enterprise and extra-enterprise, must deal with extensive delays in obtaining an appointment for their patients (regardless of the lead times of the clinics). Clinics have the extra burden of communicating the appointment to the patient long after they have left the provider's office. Adding to the problem is the fact that the appointment was made with no patient input; hence the appointments are often not suitable for the patient. These factors contribute greatly to the exorbitant “no show” rates experienced across many health systems, particularly public systems.
Current operational approaches wind up holding a large unscheduled backlog of referral orders, with some referrals being as much as 9-12 months old. Many of these patients need relatively basic care, but they are in an “out of sight/out of mind” status with their health care providers.
In building an effective referral system, addressing just the transporting of referrals as by implementing Internet order entry alone provides little improvement to the process. A method to address a range of needs is required. These needs include:                Insuring that proper workups are done before the consultation        Defining and creating prerequisite orders for various diagnostic tests        Communicating the appropriate “best practice” protocol for healthcare        Insuring that first level providers are taking all the steps they can before referring        Confirming that the order is directed to the appropriate clinic        Determining the level of clinical need or acuity        Supporting various levels of urgency        
In the healthcare industry, physicians are the only individuals who have the full knowledge required to define clinical rules that can best accomplish these goals. However, physicians are not trained to develop rules in a manner that a programmer can use to transfer the rule into XML or similar computer code. A standardized method of documentation is required to bridge the gulf between the medical and information technology worlds.